Menstrual Disorders Flashcards
Types of menstrual Disorders (7)
Amenorrhoea –> lack of periods
Dysmenorrhoea –> painful periods
Menorrhagia –> heavy or long periods (HMB)
Metrorrhagia –> irregular or spotting
Dysfunctional uterine bleeding (DUB) & premenstrual syndrome (PMS)
Definition of Heavy menstrual bleeding (HMB)
Excessive blood loss which interferes with a woman’s physical, emotional, social or material quality of life (NICE 2007)
Incidence of HMB
1/20 women between 30-49 see their GP each year for HMB –>accounts for 12% of gynae OP referrals
Medical Tx costs –£7million
Surgical Tx costs– £98.4million
Treatment of HMB
Used to treat with hysterectomy (60%)
Pharmacotherapy if no adnormality or fibroids USS then treat surgically
Causes of HMB
Fibroids Endometriosis or adenomyosis Endometrial or cervical polyps Infection or Cancer Pregnancy Thromopathies or thyroid disease
Fibroids
Can be Submucosal (growing into the inside of the uterus)
Can be subserosal (growing out of the surface of the uterus)
Assessment of HMB – History
Duration of symptoms Cycle length and bleed duration Associated symptoms (pain/dyspareunia) or intermenstrual or postcoital bleeding Smear history PMH and POH
Assessment of HMB – Examiation
General –> then abdominal –> then speculum –> then bimanual
Assessment of HMB – Investigations
FBC and thyroid test if indicated
USS (transvaginal)
Hysteroscopy or Laparoscopy
If persistent, in women >45rs or unresponsive to treatment –> endometrial biopsy may be indicated
Assessment of HMB – Investigations which are not needed
Measurements of blood loss Serum ferritin test Female hormone tests Saline infusion sonography or MRI as a first line investgation Dilatation and Curettage
Surgical treatments of HMB
If want to retain fertility–> Uterine artery embolisation or myomectomy
If no desire to retain fertility–> Endometrial ablation or hysterectomy
Pharmacotherapy for HMB
Coagulants (tranexamic or mefenamic acid)
IUS (mirena)
Combined or progestagen only pills
Other–> NSAIDs or GnRH analogues
Mirena coil
Prevents endomentrial proliferation by progestagen release
A contraceptive with no impact on future fertility
Can cause irregular bleeding and hormone related side effects and, rarely, uterine perforation
Tranexamic acid
Oral antifibrinolytic (Non-hormonal) and can be used along side investigation for up to 3 cycles–> continue if improvement
Not a contraceptive with no effect on fertility
SEs–> indigestion, diarrhoea, headaches
NSAIDs
Reduce production of prostaglandins,often used for dysmenorrhoea
No contraceptive effect/on fertility
SEs–>indigestions, diarrhoea, asthma and GI bleeding
COC
acts by preventing endometrial proliferation, so contraceptive without long term impact on fertility
SEs–> mood changes, headache, nasea, fluid retention, breast tenderness, increased risk of DVT/stroke/MI
Progestagen only pill (Norethisterone)
Taken day 5-26 of cycle
Contraceptive which prevents endometrial proliferation
SEs–> weight gain, bloating, breast tenderness, headaches, acne, depression
Progestagen Injection (Depo-provera)
Contraceptive which prevents endometrial proliferation
SEs–> weight gain, bloating, breast tenderness, headaches,amenorrhoea, less commonly bone density loss
GnRH analogues
An injection which stops estrogen and progesterone production–> not a contraceptive, if used for more than 6 months HRT is indicated
SEs–> menopausal symptoms and low risk of osteoporosis
Hysteroscopic Endometrial Ablation
First used Rollerball, now balloon and microwave
Destroys the endometrium so impacts fertility
Still should consider contraception
Can cause discharge, perforation or require further surgery
Medical treatment protocols of HMB
Pharmacological–> Mirena IUS (must be used for 12 months or more)–> Tranexamic acid OR NSAIDs OR COC –> Progestagen only method
Myomectomy
Can be abdominal or hysteroscopic
Aims to retain fertility but small risk of hysterectomy during abdominal myomectomy
Can cause haemorrhage, infection, adhesions and need for more surgery
Hysterectomy
Can also take ovaries, can be subtotal or total
1st line vaginal, 2nd line abdominal
Can lead to infection, haemorrhage, DVT or urinary dysfunction
Uterine artery embolisation (UAE)
Used to treat large fibroids avoiding surgery and sparing the uterus–> particles are injected to the uterine artery to block the blood supply to the fibroid
Aim to preserve fertility but can lead to premature menopause (also discharge, post-UAE syndrome, infection or haemorrhage)
Subtotal hysterectomy
Just the body of the uterus is removed, so the cervix is still in place
Total hysterectomy
Uterus and cervix removed
Preferred because there is no risk of cervical cancer
Norethisterone in menorrhagia
5mg can be used as short term option to rapidly stop heavy menstrual bleeding
